OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Women's Preventive Health Services Survey

IC 225622 under ICR 201702-0920-004 · OMB 0920-1200.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Women's Preventive Health Services Survey Form
WPHSS questionnaire
Attachment 3. WPHSS_Survey with consent_English.docx 		Form
Survey screenshots - English
Attachment 6. WPHSS_Survey Screenshots_English.pdf 		Form
Survey screenshots - Spanish
Attachment 7. WPHSS_ Survey Screenshots_Spanish.pdf 		Form
Attachment 5. WPHSS_Web Instructions Bilingual.docx
Web instructions		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form none WPHSS questionnaire Attachment 3. WPHSS_Survey with consent_English.docx Yes Yes Fillable Fileable
Form none Survey screenshots - English Attachment 6. WPHSS_Survey Screenshots_English.pdf Yes Yes Fillable Fileable
Form none Survey screenshots - Spanish Attachment 7. WPHSS_ Survey Screenshots_Spanish.pdf Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,338 0 2,338 0 0 0
Annual IC Time Burden (Hours) 974 0 974 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Web instructions Attachment 5. WPHSS_Web Instructions Bilingual.docx 02/08/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.